quality, risk and patient safety reporthealthcareathome.ca/northeast/en/performance...number of days...

Submitted to: Board of Directors March 4, 2016 Analysis and Ideas for Improvement Contributed by Staff of the North East CCAC

Date of Report: February 19, 2016

Quality, Risk and Patient Safety Report Fiscal Year 2015-16, Third Quarter

Quality, Risk and Patient Safety Report, Fiscal Year 2015-16, Third Quarter of 38

INTRODUCTION

TABLE OF CONTENTS

1. INTRODUCTION .......................................................................................................................................................... 3

2. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE .............................................................................. 4

a. Quality, Risk and Patient Safety Committee (Operational) ............................................................................ 4

b. Patient Safety Plan .......................................................................................................................................... 4

c. Quality Improvement Plan (QIP) ..................................................................................................................... 4

d. Document Control (Policies, Procedures and Forms) ..................................................................................... 4

e. Risk Events and Feedback (REF) ...................................................................................................................... 4

f. Client and Caregiver Experience Evaluation (CCEE) ........................................................................................ 5

3. ACCESSIBLE: Wait time for CCAC services ................................................................................................................. 6

4. ACCESSIBLE: Access to long-term care home .......................................................................................................... 10

5. EFFECTIVE: Keeping people healthy in home care .................................................................................................. 12

6. SAFE: Avoiding harm in home care and the community ......................................................................................... 17

7. PATIENT-CENTRED: Meeting patients’ needs and preferences ............................................................................... 20

8. APPROPRIATELY RESOURCED: Healthy work environment ..................................................................................... 27

11. Patient Safety Plan Progress Report ........................................................................................................................ 30

APPENDIX A: ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT STRATEGIES .............................................................. 33

APPENDIX B: DEFINITIONS .................................................................................................................................................... 36

APPENDIX C: INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT ................................................................ 37

APPENDIX D: DATA SOURCES ................................................................................................................................................ 38


INTRODUCTION

1. INTRODUCTION

Home care is an important foundation for supporting an integrated health care system. Home care has a unique function as a key linkage point between various settings of care, such as acute hospitals, emergency departments, long-term care homes and various clinical services. Home care services are intended to meet patients’ needs in an individualized and comprehensive manner, and go beyond physical and mental health care to engage social supports as well.1 To ensure that the NE CCAC is monitoring indicators across the quality spectrum, the report has been organized to link indicators to the applicable attribute of quality. The nine attributes of quality that reflect a high performing health system include: accessible, effective, safe, patient-centered, equitable, efficient, appropriately resourced, integrated and focused on population health. The report also incorporates results from the Quality Improvement Plan and the Patient Safety Plan. The report includes data to December 31, 2015, the end of third quarter for fiscal year 2015-16. Status reports and quality improvement strategy updates are current as of the date of the report.

1. Keep me safe

2. Heal me

3. Be nice to me

… in this order

©2006 Healthcare Performance improvement,

LLC. ALL RIGHTS RESERVED.

1 Ontario Local Health Integration Networks M-SAA Performance Technical Specifications Version: December 18, 2008

uUPDATE


UPDATE

2. ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT UPDATE Appendix A provides a description of all the NE CCAC’s enterprise-wide quality and risk management strategies. This section provides an overview of updates in the 3rd quarter.

a. Quality, Risk and Patient Safety Committee (Operational)

The Committee met in November, December and January to discuss topics such as implementation of the “New” Risk Event and Feedback System; Patient Safety Event reports; 2016-17 QIP Development; CCEE Annual Report 2014-15; Quality, Risk & Patient Safety Report – 2nd Quarter; Education Highlights (Communicating with Care, REFS training, Crucial Conversations) and planning for future offerings to support patient experience; Terms of Reference; additional CCEE optional surveys such as CaregiverVoices for Caregivers of Palliative Care Patients, Clinic Only Patients, Patients Referred from Hospital and Mental Health and Addictions; Safety & Service Issue Management Risk to Staff (draft for review); development of the 2016-17 Patient Safety Plan.

b. Patient Safety Plan Refer to Section 11 for the 2015-2016 Patient Safety Plan Quarterly Report. Of the 11 key initiatives/activities, 2 are completed, 7 are in progress and 2 are planned but not started.

c. Quality Improvement Plan (QIP) The 2015-16 NE CCAC QIP status updates on the priority indicators are incorporated into this report. (Click on link to jump directly to each section.)

5-Day Wait Time – Nursing; Personal Support Complex Patients

Unplanned, Less Urgent Emergency Department Visits

Unplanned Hospital Readmissions

Falls

Patient Experience

Development of the 2016-17 QIP included engagement presentations to various staff groups and committees to elicit possible change ideas related to the priority indicators and the additional palliative indicator.

d. Document Control (Policies, Procedures and Forms) The Forms Management Committee continues to review all new and revised forms. The Committee met on October November and December 2015 to review development of standards/guidelines for form developers and reviewers and progress with streamlining and automating the form review and approval process.

e. Risk Events and Feedback (REF) The new REF System was configured on the Intelex software platform and rolled out to staff on October 1, 2015. In Q3, there were 299 records submitted about patient safety events, complaints and compliments as users began using the system. User support was offered by Patient Relations and Quality staff as needed. A survey of user experience is planned in February 2016. As a result of technical issues, work was delayed on configuring the module that will replace the Occupational Health and Safety reporting function from the legacy system. With technical issues resolved, this work is now progressing.

uUPDATE


UPDATE

f. Client and Caregiver Experience Evaluation (CCEE) Survey results for Year 3 (2014-15) were presented to the Quality, Risk and Patient Safety Committee in November, to the Patient Services and Quality Committee of the board in December and to the Operations Network in January. A Year 3 ‘Significant Results and Top Priority Areas of Focus’ report was presented to Executive Team in December to identify areas of greatest opportunities to improve the overall rating of care. A report was prepared for the French Language Services Operational Committee presenting results from the CCEE survey language questions and a synopsis of patient comments about receiving services in their preferred language. A report was prepared for the Performance and Relations team highlighting priority areas of focus for a service provider organization. The Client Caregiver Experience Evaluation provincial steering committee has finalized other survey components to evaluate services that are not in scope in the existing core survey, including the Caregiver Voice Survey of family members/caregivers of palliative/end of life patients following their death; Clinic Only patients; Patients Referred from Hospital Discharge; and Mental Health and Addictions Nursing program clients. These new surveys are optional for CCACs. The North East CCAC is deferring purchase of additional surveys at this time.

The semi-annual 2015-16 CCEE report will be available in February 2016.


ACCESSIBLE

3. ACCESSIBLE: Wait time for CCAC services

What we want Consequences if we don’t get it To whom does this matter?

Short wait times and efficient care processes for CCAC services.

Long wait lists represent a barrier to accessibility for patients. In some cases a delay in providing care could result in a crisis and the need for more intensive forms of care.

Patients seeking accessibility to CCAC services in north eastern Ontario.

Indicators and Trends for Wait Time for CCAC Services Analysis and Ideas for Improvement

Q3 Value: 42 days 2015-16 Target: ≤48 days 2014-15 Performance Standard: <60 days Analysis: The metric is at 42 days which meets and exceeds the target. Each month data analysis is completed at a patient level to identify opportunities for further improvements. Quality Improvement Strategy:

A continued focus on reducing patient wait times for therapy services

We have been informed by the NE LHIN that the target will be less than 21 days for all CCACs in 2016-17.

Data Source: Business Intelligence

Business Intelligence > NE Reports > Indicators > Wait Time - 90th Percentile Community Referral to 1st Service

M-SAA Quarterly Progress Report

Q3 result: 52.4 days Quality Improvement Strategy: The “Access to Care Strategy for Therapy Services” aims to provide patients and children with quick access to high quality care. Clinical Services therapy staff members are testing solutions to reduce the wait time for therapy services. Some of the quality improvement ideas include:

Maximizing the use of OHIP funded PT clinics which are becoming operational across the NE (for patients who have the strength and mobility to access the clinics)

Reducing travel time through geographic assignment of therapy staff

Documenting in CHRIS and using integrated eform templates to speed up documentation

Implementing a small “short stay” rehabilitation team of care coordinators to reduce the patient waiting time

0

10

20

30

40

50

60

70

80

90

100

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

# o

f D

ays

Quarter, Fiscal Year

Wait Time for Patients Referred from Community Settings to Community Home Care

0

20

40

60

80

100

120

140

160

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

# o

f d

ays

Quarter/Year

Wait Time for SRC 92 Patients Referred from Community Settings to Community Home Care

BETTER

BETTER


ACCESSIBLE


Wait list integrity audits on a regular basis are completed to ensure each patient on the therapy waiting list is available for care (i.e. not admitted to a rehabilitation bed, hospital, etc.)

Data Source: Business Intelligence

Business Intelligence > NE Reports > Indicators > Wait Time – 90th Percentile Community Referral to 1st Service 90th Percentile Wait Time from Community Setting to Community Home Care

Business Intelligence > NE Reports > Care Coordination > Wait List Information > Service Waitlist Analysis

2015-16 Q1 Value: 9 days (last available report) 2015-16 Target: ≤ 6 days 2015-16: Performance Standard: ≤ 6.6 days This M-SAA indicator defined by the LHIN measures the number of days from the hospital discharge date to the first non-case management service for patients whose referral source was the hospital. Analysis: This result does not meet the established target and performance standard for Q1, 2015-16, the most recent data available. Further analysis is not possible without access to the actual data sources. Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. CCAC is not able to replicate baseline numbers and identifies a large variance in referral to counts. Six month or more delay in data availability impacts reporting abilities. Data Source: Ministry of Health and Long-Term Care, M-SAA Indicators, MSAA 1.1.access_wt1

0

100

200

300

400

500

600

700

800

900

JAN'15

FEB'15

MAR'15

APR'15

MAY'15

JUN'15

JUL'15

AUG'15

SEP'15

OCT'15

NOV'15

DEC'15

# o

f C

lien

ts

Month, Year

Therapy (SRC 92) Waitlist

OT PT SW SLP Nutrition

0

2

4

6

8

10

12

14

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

# o

f D

ays


Wait Time (Days) from Hospital Discharge to Service Initiation

BETTER


ACCESSIBLE


Quality Improvement Plan

Objective: To reduce service wait times Outcome measure/indicator: 5-day wait time for Home Care service measured from Initial Authorization Date by Care Coordinator as start time to First Service Date as the end time. Nursing Service: Q3 Result: 93.63% 2015-16 Target: ≥ 94.0% Personal Support – Complex Patient Only Q3 Result: 85.65% 2015-16 Target: ≥ 84.80% Analysis: The result for Nursing is slightly lower than the target. The result for Personal Support – Complex Patients is slightly higher than the target. A contributing factor relates to each patient being available for care. Patients with complex needs often require pre-hospital discharge planning and advanced care planning before PSW services begin in the home. This proactive planning enables safe transitions from hospital to home. We have completed education sessions for care coordination teams to ensure the use of the “patient availability date” field in CHRIS and are tracking this performance indicator as well. Additionally we have submitted a briefing note to the OA CCAC and NE LHIN to support provincial discussions with the MOHLTC regarding the use of patient availability date in this metric. Data Source: Business Intelligence>Indicators>5 Day Wait Times

80%

85%

90%

95%

100%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Pe

rce

nta

ge o

f P

atie

nts

Quarter, Year

5 Day Wait Time - Nursing VisitsPercentage of Patients Served Within 5 Days of

Service Authorization

70%

75%

80%

85%

90%

95%

100%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Pe

rce

nta

ge o

f P

atie

nts

Quarter, Year

5 Day Wait Time - Personal Support for Complex Patients

Percentage of Patients Served Within 5 Days of Service Authorization

BETTER

BETTER


ACCESSIBLE


Change

Planned improvement initiatives (Change

Ideas) Methods Process measures

Goal for change ideas

Progress Report

Understand contributing factors causing delays over 5 days to delivery of:

First personal support service to complex patients.

First nursing service to patients.

Conduct monthly chart audit of a sample of patient charts over a period of 3 to 6 months where the 5-day wait time was not achieved for review by stakeholders and committees.

Between 3 and 6 monthly chart audit reports are prepared and submitted to stakeholders and committees.

Monthly chart audit results and analysis are completed and shared with relevant stakeholders and committees for identification of opportunities for quality improvement.

Data analysis is completed each month to identify reasons for delays in first service beyond 5 days. This includes a review of the patient record. As a result of the findings, several actions were taken:

A contributing factor is the need to respect patient and caregiver choice in scheduling their first visit.

We are ensuring Care Coordinators are using the ‘Patient Availability Date’ in CHRIS so that variances can be explained.

We are exploring methods to speed up various internal processes impacting this metric

We are working with internal nursing staff to ensure Nurse Practitioners, Rapid Response Nurses and Enterostomal Therapists are meeting this target.


ACCESSIBLE

4. ACCESSIBLE: Access to long-term care home


Short wait times to get into a long-term care home.

If the person is waiting at home, a heavy burden could be placed on loved ones who are caring for the individual. If the person is waiting in hospital, the hospital bed is used unnecessarily, which can lead to emergency department overcrowding and wasted resources.

Patients in north eastern Ontario who are currently on the wait list for placement into a long-term care home, along with their families and caregivers.

People get their first choice of long-term care home.

Being placed in a second or third choice home may mean being placed further away from loved ones or in a home that does not specialize in meeting one’s ethnic, cultural or medical needs. Residents can move to a higher-ranked choice later, but that can be inconvenient and disruptive to the residents’ continuity of care.

Indicators and Trends for Access to Long-Term Care Home Analysis and Ideas for Improvement

As of December 31, 2015, patients on wait list including transfers: 2431 The number of individuals making application and waiting for initial placement has steadily increased since January 2014 and continues to exceed the number of available beds in Long-Term Care Homes (LTCH). Fluctuations of the wait list are based on the number of applications pending for placement and the number of available LTCH beds at any point in time. This metric also includes patients admitted to a LTCH and waiting for transfer to their first choice. A decrease in the availability of male basic beds has been observed within our region. This has impacted the community crisis waitlist as male patients requiring a basic accommodation are waiting significantly longer than the same time last year. We are working with the LTCH’s to switch rooms from female to male as able. We will continue to monitor the impacts over the next quarter. Data Source: Business Intelligence > NE Reports > Care Coordination > Placement > Placement Waitlist

2050

2100

2150

2200

2250

2300

2350

2400

2450

2500

Jan'15

Feb'15

Mar'15

Apr'15

May'15

Jun'15

Jul'15

Aug'15

Sep'15

Oct'15

Nov'15

Dec'15

Nu

mb

er

of

Clie

nts

Month, Year

Total Long Stay Wait List, with Transfers

BETTER


ACCESSIBLE

Indicators and Trends for Access to Long-Term Care Home Analysis and Ideas for Improvement

January to December 2015 Average: 1st Choice: 58% The percentage of patients placed into their 1st choice of LTC home remained consistent and within normal variation in the 12-month period from January to December 2015. Data Source: Business Intelligence > SSRS Report List > Indicators > Other Misc. Indicators > LT Placements by Ranking

0%

10%

20%

30%

40%

50%

60%

70%

Jan'15

Feb'15

Mar'15

Apr'15

May'15

Jun'15

Jul'15

Aug'15

Sep'15

Oct'15

Nov'15

Dec'15

% o

f C

lien

ts P

lace

d

Month, Year

% Placed to 1st Choice of LTC Home

1st Choice

BETTER


EFFECTIVE

5. EFFECTIVE: Keeping people healthy in home care

What we want How to get it Consequences if we don’t get it To whom does this matter?

Patients receive effective home care to improve their health, maintain it or prevent deterioration to avoid hospitalization and/or admission to long-term care homes.

Promote activities to maintain health and independence (e.g. preserving bladder function and mobility, controlling pain, preserving communication ability, memory and thinking abilities and avoiding depression and weight loss).

Patients experience loss of independence, reduced quality of life through admissions and/or readmissions to hospital and/or admission to long-term care home.

All CCAC patients

Indicators and Trends for Keeping People Healthy in Home Care Analysis and Ideas for Improvement

Q3 Value (as of December 31, 2015): 67.9%* Target: ≥ 60% Performance Standard: < 60% The percentage of complex patients who are maintained in their home exceeded the target and performance standard in December 2015. Through the Integrated Discharge Program coupled with the Home First philosophy, local health service partners are creating a cultural shift in practice to reduce the number of ALC-LTC patients. Note: the data source for this metric changed as of April 2015. The graph has been updated to reflect the results based on the new Business Intelligence report. The metric for this report is being reviewed by Business Intelligence. Data Source: Business Intelligence>BSC and MSAA Reporting>M-SAA and LHIN Reporting> M-SAA 2014-17>Percentage of Complex Clients Remaining in the Community for 60 Days Post Hospital Discharge (using ED Notification data)

30%

40%

50%

60%

70%

80%

90%

100%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

% o

f co

mp

lex

pat

ien

ts

Month/Year

Complex Patients Remaining in Community for 60 Days or More Post Hospital Discharge

BETTER


EFFECTIVE


Q3 Value = 86% M-SAA 2015-16 Target: ≥ 84% M-SAA 2015-16 Performance Standard: ≥ 75% Analysis: The percentage of patients placed in LTC Homes with MAPLe scores High or Very High is slightly higher than the established target. Most people placed into a LTC home have very heavy needs that require them to be in that type of setting; however, one in five people placed in LTC have relatively lighter needs. Ideas for Improvement: The community crisis escalation process assists with ensuring that the most appropriate patients are placed into LTC. Ongoing monitoring of MAPLe scores continues. Data Sources:

Business Intelligence > NE Reports > Indicators > MSAA 2014-2017> MSAA - Patients Placed in LTC with MAPLe High or Very High as Portion of Total Patients Placed

Q3 Value: 3933 patients 2015-16 Target: ≥ 3000 patients 2015-16 Performance Standard: > 2850 patients The number of patients with high and very high MAPLe scores living at home with CCAC support exceeds the established target. Data Source: M-SAA Quarterly Progress Report to the NE LHIN: (2014-2017)

60%

65%

70%

75%

80%

85%

90%

95%

100%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

% o

f P

atie

nts


Patients placed in LTC Home with MAPLe SCORES High or Very High (i.e. appropriately)

2500

2600

2700

2800

2900

3000

3100

3200

3300

3400

3500

3600

3700

3800

3900

4000

4100

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

# o

f P

atie

nts


Patients with MAPLe scores high and very high living in the community supported by CCAC

BETTER

BETTER


EFFECTIVE


Q3 average: 18.70% Target: ≤17% Performance Standard: ≤18.7% Analysis: The Q3 average ALC-Acute rate for the 4 Hub Hospitals has decreased and is meets the performance standard for 2015-16. Ideas for Improvement:

NE CCAC Directors, Care Coordination, continue to work closely with all hospitals.

Crisis designation relieved for all hospitals within Algoma District for the first time in a long while – none remain with crisis designation.

By March 31, 2016- E-referral will be implemented with all hospitals in the NECCCAC except SAH, NBRHC and WPSHC.

Planning is underway to implement e-Referral at these remaining hospitals in 016/17 pending funding by the NELHIN.

E-Notification has been implemented with all hospitals in the North East except West Parry Sound Health Centre.

Patient Viewer has been implemented with all hospitals in the North East.

ALC Long Stay/Hard to Serve Committees continue to work with patients designated as hard to serve.

Access to Care, Access to Care (ATC), a company that provides high-quality information products and services to help improve performance and ensure accountability within health care organizations, is working with the NE LHIN to review Wait Times Information System (WTIS) consistency in ALC reporting.

Improvement work with individual hospitals continues, with a focus on the specific improvements with each hospital (e.g., SAH Flow Process Improvement Project).

Data Source: M-SAA Quarterly Progress Report to the NE LHIN (H1) (2014-2017)

0%

5%

10%

15%

20%

25%

30%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Ave

rage

ALC

Acu

te R

ate

Quarter, Year

NE LHIN ALC Acute Rate 4 Hub Hospitals

BETTER


EFFECTIVE



Q3 2015-16 Result: not available Last Available Result: 14.8% (Q1 2015-16)* Target: ≤ 13.8% Analysis: The 4-quarter total result for Q2 2014-15 to Q1 2015-16 is 13.8%, identical to the previous 4-quarter result. Ideas for Improvement: The NECCAC is working with a rural and HUB hospital to review and analyze emergency room visits by CCAC patients. The hospitals are Timmins and District Hospital and MICs Group of Health Services. Data Source: OACCAC Reporting Site: CCAC Metrics for Quality Improvement Plan Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. Delay in data availability will impact reporting abilities.

Change




Progress Report

Collaborate with at least one hub hospital and one small hospital to understand the underlying causes of unplanned ED visits by CCAC patients and to develop strategies that support patient's care needs in the home.

Monthly ED Notification Reports will be analyzed and reviewed by the designated work group (hospital and CCAC)for accuracy and to discover cause(s) of unplanned ED visits over a period of 3 to 6 months (to be determined by the work group).

Number of accurate monthly reports available for review and analysis by the designated work group (hospital and CCAC).

Completed analysis outlining root cause(s) of patients returning to the ED during the designated period with preliminary ideas for improvement.

The Director, Care Coordination, met with TADH and District Hospital and

MICs Group of Health Services to review planned and unplanned emergency department visits. Follow-up meetings are now scheduled to identify root causes and potential strategies for improvement. ED visits were also reviewed with the following hospitals in October: o Kirkland Lake and District

Hospital o Englehart and District Hospital o Temiskaming Hospital o St. Joseph’s General Hospital o Hornepayne Community

Hospital

0%

5%

10%

15%

20%

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Pe

rce

nta

ge o

f h

om

e c

are

r p

atie

nts

Quarter, Year

Unplanned, Less Urgent Emergency Department Visits Within 30 Days of Discharge from Hospital

BETTER


EFFECTIVE



Q3 2015-16 Result: not available Last Available Result: 19.1% (Q1 2015-16) Target: ≤ 18.2% Analysis: The result for the four-quarter period from Q2 2014-15 to Q1 2015-16 is 18.3%, slightly above the target and a decrease from the previous four-quarter result of 20.5% (Q2 2013-14 to Q1 2014-15). Ideas for Improvement: The NECCAC is working with a rural and HUB hospital to review and analyze hospital readmissions of CCAC patients within 30 days of discharge from hospital. The hospitals are Timmins and District Hospital and MICs Group of Health Services. Data Source: OACCAC Reporting Site: CCAC Metrics for


Note: The CCAC sector is dependent on the Ministry of Health and Long-Term Care for this data. Delay in data availability will impact reporting abilities.

Change




Progress Report

1)Collaborate with at least one hub hospital and one small hospital to understand the underlying causes of avoidable hospital readmissions by CCAC patients and to develop strategies that support patient's care needs in the home.

Monthly Reports of unplanned hospital readmissions will be analyzed and reviewed by the designated work group (hospital and CCAC)for accuracy and to discover cause(s) of these readmissions over a period of 3 to 6 months (to be determined by the work group).

Number of accurate monthly reports available for review and analysis by the designated work group (hospital and CCAC) and one final summary report.

Completed analysis outlining factors contributing to hospital readmissions during the designated time period with development of preliminary ideas for improvement.

The Director, Care Coordination, met with Timmins and District Hospital and MICs Group of Health Services to review hospital readmissions. Weekly meetings are planned to further discuss strategies to reduce hospital readmissions. As of Nov. 17/2015, readmission information of patients discharged to NE CCAC for Q1 & Q2 2015-16 from TADH (Timmins & District Hospital), MICs (Anson, Bingham & Lady Minto hospitals), and SAH (Sault Area Hospital) was reviewed. There are plans to meet again with these hospitals to drill down further to root causes. At SAH, this information will also be presented to the Primary Care group.

10%

12%

14%

16%

18%

20%

22%

24%

Q213-14

Q313-14

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Pe

rce

nta

ge o

f H

om

e C

are

Pat

ien

ts

Quarter, Year

Unplanned Hospital Readmissions Within 30 Days of Hospital Discharge

BETTER


SAFE

6. SAFE: Avoiding harm in home care and the community

What we want How to get it Consequences if we don’t get it To whom does this matter?

No risk events and complete patient records to identify high risk patients

Implement preventative measures to minimize risk events to the extent possible. Monitor completeness of patient records.

Risk of temporary or permanent disability and death; more emergency department visits and hospitalizations. High risk patients may not get the help they need in an emergency/disaster situation

All patients, caregivers and family members. Those identified as long-stay home care patients are at particular risk.

Indicators and Trends for Avoiding Harm in Home Care and the Community

Analysis and Ideas for Improvement

Q3 Result: 2.88 risk events per 1000 patients

(average)

Analysis: The number of risk events reported per 1000 patients fluctuated slightly throughout the quarter but remained within expectations. Ideas for Improvement: The new reporting system underwent final review and policies were updated to reflect changes. The new system began collecting reports on October 1, 2015

Data Source: Risk Event and Feedback System (Legacy REFS Report 10-005; New REFS Report 00179)

Analysis: The data source for this metric has changed as of October 1, 2015. The graph has been updated to reflect the results based on the new risk event and feedback system (Intelex) and only includes data from this quarter.

Ideas for Improvement:

The new REFS system will greatly improve ability to collect data and run reports to identify trends. The category “Service/Care Delivery” may require further breakdown identify any trends.

Data Source: Risk Event and Feedback System

(Legacy REFS Report 06-003, New 00161)

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

JAN'15

FEB'15

MAR'15

APR'15

MAY'15

JUN'15

JUL'15

AUG'15

SEP'15

OCT'15

NOV'15

DEC'15

# o

f Ev

en

ts /

# C

lien

ts (

10

00

s)

Month, Year

Total Number of Patient Risk Events per 1000 PatientsR12 Jan-15 to Dec-15

29

23

18

13 12

0

5

10

15

20

25

30

35

Service/CareDelivery

MedicalEquipment

Medication/Fluid Behaviour Medical Supplies

Nu

mb

er

of

Clie

nt

Ris

k Ev

en

ts

Specific Event Type

# of Patient Risk Events by Specific Event Type (Top 5)Oct-15 to Dec-15


SAFE



Risk Level Definitions

Very High There is significant uncontrolled risk to the patient or organization.

The situation requires the immediate attention of senior leaders for comprehensive corrective action and resolution.

Escalation to at least the Senior Director level is mandatory for resolution.

High There is significant risk to the patient or organization that requires corrective action to prevent recurrence in the future.

Escalation to at least the Director level is required for resolution.

Medium There is unresolved risk to the patient or organization that requires attention.

Formal corrective actions are not mandatory but highly recommended to prevent recurrence in the future.

Escalation to the Manager level is required for resolution. Low There is some risk to the patient or organization but the

situation can be resolved through normal existing procedures.

Corrective action is not required but may be developed if deemed necessary.

Authority for resolution remains at the front line level and escalation may be required if deemed necessary.

Very Low There is little risk to the patient or organization with no specific corrective action required.

Correction of the issue is within authority of the front line staff involved and does not necessarily require escalation.

Analysis:

Of the 137 patient risk events reported in Q3, 7 were reported as “high” (5.1%), 70 reported as “medium” (51.1%) and 49 reported as “low” (35.8%). The remaining 11 reports were “very low” (8.0%). The 7 reported as “high” were categorized as follows:

Medication/Fluid Errors- 6

Clinical Administration/Task Assignment-1 Note: Missed visits causing patient harm are documented in the Risk Event and Feedback System (REFS) whereas missed visits where there is no patient harm are captured in CHRIS.

Ideas for Improvement:

Each patient risk event is reviewed for accuracy and appropriate follow-up when submitted.

Unresolved patient safety risk events are reviewed regularly. Follow-up with management staff (investigators) occurs as needed.

A Director, Clinical Services has been appointed as the Lead for overseeing infusion related issues.

Data Source:

Risk Event and Feedback System (Legacy REFS Reports 10-007/10-023, New 00164/00181)

Note: Data from January to September 2015 taken from Executive Team Patient Safety Reports; data from October to December 2015 extracted from new Risk Event and Feedback System (Intelex).

0

10

20

30

40

50

60

JAN'15

FEB'15

MAR'15

APR'15

MAY'15

JUN'15

JUL'15

AUG'15

SEP'15

OCT'15

NOV'15

DEC'15

Nu

mb

er

of

Ris

k Ev

en

ts

Month, Year

Number of Risk Events by Risk LevelR12 Jan-15 to Dec-15

VeryHighHigh

Medium

Low

VeryLow


SAFE




Objective: The incidence of falls in adult long-stay home care patients will be reduced. Outcome Measure/Indicator: Percentage of long-stay patients who record a fall on follow-up RAI HC assessment. Target: ≤ 35.3% Performance Standard: ≤ 39.0% Q3 Result: 37.6% Analysis: The current rate of 37.6% does not meet the QIP target but is within the performance standard. Results have remained consistently in this range since Fiscal 2012-13. The patient population that is included in this metric has seen a significant increase in the average RAI score. It is not unreasonable that these increasingly complex patients will have a higher rate of falls even with the success of the falls prevention program. Improvement Initiatives: Care Coordination staff are completing home and safety assessments as part of their home visit (see results below). Medication review for high risk patients is also being done. Patients are referred to therapy for mobility and assistive devices, as appropriate. Data Source:

OACCAC Members Portal, Reporting Site, MSAA Indicators 2011-2014 Reports

Business Intelligence: Home Safety Risk Assessment Report

Change




Progress Report

1) Increase use of the Home Safety Risk Assessment as a health teaching tool with patients about safety of the home environment.

A monthly CHRIS report will be produced for review and analysis by the Falls Prevention Committee and the Quality, Risk and Patient Safety Committee on the percentage of completed Home Safety Risk Assessments completed in that period.

Percentage of completed Home Safety Risk Assessments for long-stay patients receiving an in-home assessment.

80% of patients receiving a RAI-HC during a one-month period have a completed Home Safety Risk Assessment noted in CHRIS.

Q3 – 83.53%

This measure has steadily improved from the baseline result of 51% in Q4, 2014-15 and and the goal for change has been met.

In October, Care Coordination managers completed further education with staff about completion of the Home Safety Risk Assessment.

15%

20%

25%

30%

35%

40%

45%

50%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Pe

rce

nta

ge o

f P

atie

nts

Quarter, Year

Prevalence of Falls for Adult Long-Stay Home Care Clients

BETTER


PATIENT CENTRED

7. PATIENT-CENTRED: Meeting patients’ needs and preferences


Patients who are satisfied with the services that they receive from the NE CCAC and our service providers.

Dissatisfied patients. Potential for internal and external appeals, legal proceedings, and loss of reputation.

Patients, caregivers, family members, NE CCAC staff and service providers.

Patient-Centered Indicators and Trends Analysis and Ideas for Improvement

Q3 Result: 2.2 complaints per 1000 patients (average)

Analysis: The overall rate of complaints documented per 1000 patients in Q3 was lower than previous reporting periods but consistent with normal variation.

Ideas for Improvement: The new reporting system underwent final review and policies were updated to reflect changes. The new system began collecting reports as of October 1, 2015.

Data Source: Risk Event and Feedback System (Legacy REFS Report 01-001, New 00160)

Analysis: The top 5 types of complaints in Q3 have changed due to the data being pulled from the new risk event and feedback system.

Ideas for Improvement: NE CCAC staff follow-up with patients, caregivers and Service Providers as required when investigating patient complaints. Actions are taken to reach a satisfactory resolution of the complaint and to escalate issues that require intervention by a manager or director. Most complaints are resolved by the Care Coordinator and/or Care Coordination Manager in collaboration with internal clinicians and/or external service providers. Data Source: Risk Event and Feedback System (Legacy REFS Report 01-002, New 00192) Note: The data source for this metric has changed as of October 1, 2015. The graph has been updated to reflect the results based on the new risk event and feedback system (Intelex) and only includes data from the last quarter.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

JAN'15

FEB'15

MAR'15

APR'15

MAY'15

JUN'15

JUL'15

AUG'15

SEP'15

OCT'15

NOV'15

DEC'15

# C

om

pla

ints

/ #

Pat

ien

ts (

10

00

s)

Month, Year

Total Number of Complaints per 1000 PatientsR12, Jan-15 to Dec-15

44

17

11

85

0

5

10

15

20

25

30

35

40

45

50

Service/CareDelivery

MedicalEquipment

ClinicalAdministration

Behaviour Communication/Reporting

Nu

mb

er

of

Co

mp

lain

ts

Complaint Category

Top 5 - Number of Complaints by Specific TypeOct-15 to Dec-15


PATIENT CENTRED


Risk Level Definitions

Very High There is significant uncontrolled risk to the patient or organization.

The situation requires the immediate attention of senior leaders for comprehensive corrective action and resolution.

Escalation to at least the Senior Director level is mandatory for resolution.

High There is significant risk to the patient or organization that requires corrective action to prevent recurrence in the future.

Escalation to at least the Director level is required for resolution.

Medium There is unresolved risk to the patient or organization that requires attention.

Formal corrective actions are not mandatory but highly recommended to prevent recurrence in the future.

Escalation to the Manager level is required for resolution.

Low There is some risk to the patient or organization but the situation can be resolved through normal existing procedures.

Corrective action is not required but may be developed if deemed necessary.

Authority for resolution remains at the front line level and escalation may be required if deemed necessary.

Very Low There is little risk to the patient or organization with no specific corrective action required.

Correction of the issue is within authority of the front line staff involved and does not necessarily require escalation.

Analysis: In Q3, there were a total of 112 complaints of which 49 (43.8.0%) were medium, 50 (44.6%) were low and 13 (11.6%) were very low in nature. There were no complaints with a high or very high risk level.

Data Source: Risk Event and Feedback System (Legacy REFS Report 01-001/10-024, New 00160/00180) The data source for this metric has changed as of October 1, 2015. The graph has been updated to reflect the results based on the new risk event and feedback system (Intelex).

0

5

10

15

20

25

30

35

40

45

50

OCT'15

NOV'15

DEC'15

Nu

mb

er

of

Co

mp

lain

ts

Month, Year

Complaints by Risk LevelOct-15 to Dec-15

Very High

High

Medium

Low

Very Low


PATIENT CENTRED


Q3 Value: 0, Year-to-date: 0 Analysis: The number of complaints about the provision of services in French remains very low with 0 complaints reported in the Risk Event and Feedback System in Q3. Data Source:

Risk Event and Feedback System

Q3 Value: 0, Year-to-date: 1

15/16 Fiscal Quarter Number

Status

In-Process Resolved

1st 0 0 0

2nd 1 0 1

3rd 0 0 0

4th N/A N/A N/A

Total 1 0 1

Data Source: Complaint Log (Action Line, MPP and Appeals)

Q3 Value: 0, Year-to-date: 0

15/16 Fiscal Quarter Number

Status

In-Process Resolved

1st 0 0 0

2nd 0 0 0

3rd 0 0 0

4th N/A N/A N/A

Total 0 0 0

Data Source: Complaint Log (Action Line, MPP and Appeals)

0

1

2

3

4

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

# o

f C

om

pla

ints

Quarter, Year

French-Language Services Complaints Reported in Risk Event and Feedback System

0

1

2

3

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Nu

mb

er

of

Ap

pe

als


Number of Internal Appeals by TypeInternal Appeals Committee

Termination

Amount

Exclusion

Eligibility

0

1

2

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Nu

mb

er

of

Ap

pe

als

Init

iate

d


Number of External Appeals by TypeHealth Services Appeal and Review Board

Termination

Amount

Exclusion

Eligibility


PATIENT CENTRED


In the 3rd quarter, 2 complaints from patients/families were referred to the North East CCAC by the Long-Term Care Action Line with regards to the following:

Service/Care Delivery

Clinical Administration Data Source: Complaint Log (Action Line, MPP and Appeals)

In Q3, there were 17 complaints or inquiries referred by MPP offices throughout the North East CCAC region and 1 from the NE LHIN. Analysis: The topics of the referred complaints or inquiries include:

Amount or type of service (6)

Accessibility – Ability to place in LTCH (4)

Coordination(3)

Continuity (3)

Medical Equipment (1)

Quality of Care (1) The Senior Director, Strategic Engagement followed up on all complaints/inquiries. Note: tracking of MPP-referred complaints began in April 2013 (Q1 13-14) and NE LHIN-referred complaints in April 2014 (Q1 14-15). Data Source: Complaint Log (Action Line, MPP and Appeals)

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Nu

mb

er

of

Cal

ls

Fiscal Year, Quarter

Number of Calls to LTC Action Line

Resolved

In-Process

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

NE LHIN 0 2 0 0 0 0 0 1

MPP 32 13 11 11 15 11 11 17

0

5

10

15

20

25

30

35

# o

f R

efe

rre

d C

om

pla

ints

/In

qu

irie

s

Quarter, Year

Complaints/Inquiries Referred to NE CCAC by MPP Offices and NE LHIN

MPP NE LHIN


PATIENT CENTRED


Objective: To improve client experience Outcome Measure/Indicator: Percent of home care patients who responded “Good”, “Very Good”, or “Excellent” on a five-point scale to any of the patient experience survey questions:

i) Overall rating of CCAC services ii) Overall rating of management/ handling of

care by Care Coordinator iii) Overall rating of service provided by service

provider Target: ≥ 90% Performance Standard: > 85.0% Year 3 Result: 92.1% Analysis: The year 3 result meets and surpasses the target and is consistent with the provincial overall result. Unweighted results for Q2 2015-16 (July to September)* for the 3 KPI 1 questions are:

Overall rating of CCAC services: 93.19% (n=455)

Overall rating of management/ handling of care by Care Coordinator: 93.92% (n=329)

Overall rating of service provided by service provider = 94.35% (n=425)

These results are consistent with Q1 results. *results are for information only and should be viewed with caution as they reflect a small sample size surveyed in one quarter. Improvement Initiatives: The table below provides a progress report on planned improvement initiatives.

Change




Results and Comments

1) Support Care Coordinators and Clinical Services staff with engagement with patients, family members, and others in difficult conversations about changes in health care needs and other difficult topics.

A quarterly progress report of the percent of staff uptake of the education module will be provided to management staff and also be included in the Quality, Risk and Patient Safety Report.

Percentage of staff who interact with patients who complete the education module

30% of staff who interact with patients complete the E-learning modules "Communicate with H.E.A.R.T." by March 31, 2016.

There is no progress provincially with procurement of the “Communicate with H.E.A.R.T” modules for interested CCACs. We are exploring other courses and products for staff who communicate with patients and caregivers with an anticipated training start date of January 2016. In May 2015, the NE CCAC hosted four hour-long sessions on “Caring Conversations” attended by 120 staff members. Staff learned techniques to help patients feel even more cared for during phone calls and in-person

93.8%

92.4%92.1%

92.9%92.4%

92.2%

90.0%

91.0%

92.0%

93.0%

94.0%

95.0%

96.0%

2012-2013 2013-2014 2014-2015

An

nu

al R

esu

lt

Fiscal Year

Client and-Caregiver Experience Evaluation (CCEE) Survey

KPI 1 - Overall Experience Results

NE CCAC Provincial Overall


PATIENT CENTRED

Change





assessments, to learn and practice skills for delivering tough news and to identify techniques to reduce stress and build resiliency. The sessions were extended to all staff, via videoconference at main sites and also via webinar. Two members of the Training and Development team completed a train the trainer course for Crucial Conversations in November 2015. The plan is to offer the session across the organization in a multi-year plan, starting with management/ supervisory staff and then on site to the branch offices. The course will be part of new employee orientation. Crucial Conversations training was launched in the Sudbury branch in December 2015. Three separate groups have been scheduled into training for a total of 32 staff who will have attended by completion of these groups (March 2016). The training will be rolled out to staff in other branches in the spring.

2) Increase staff awareness of patient experience with NE CCAC services. This will be achieved through structured communication to all staff and dissemination of reports, analysis of Key Performance Indicators to improvement teams, management teams, operational and board committees.

Survey of staff to assess level of awareness of patient experience and use of data in development of strategies to improve patient experience.

# of staff indicating increased awareness of CCEE and use of survey results in their work to improve patient experience.

50% of staff responding to the survey will agree that they are more aware of patient experience with NE CCAC services by March 31, 2016.

Year 3 annual results were received in August 2015 and have been shared with the Executive Team, the Quality Risk and Patient Safety Committee, the Patient Services and Quality Committee of the Board and the Operations Network. Action plan reports were posted on the Intranet site. KPI 1 results are also reported in this report which is shared with staff, key external stakeholders and posted on the public NE CCAC web site. A report was prepared for the French-Language Services Operational Committee with survey results for the language questions and a review of patient comments about services in French. Collaboration with Performance and Relations staff (Contracts) supports their work with Service Provider Organizations. As a result of staffing changes and other priorities, it was not feasible to engage the improvement teams to focus on specific results and develop action plans to address areas for improvement.


PATIENT CENTRED

Change





3) Development of a Patient and Family Engagement Strategy

Patient and Family Engagement Strategy is developed in accordance with Accreditation Canada standards and best practice and with review and input by the Quality, Risk and Patient Safety Committee, the Patient Services and Quality Committee of the Board of Directors and other stakeholders.

A document describing the Patient and Family Engagement Strategy is vetted with stakeholders for review by the Board of Directors.

The Patient and Family Engagement Strategy is finalized and approved by the Board of Directors by March 31, 2016.

The Draft Framework is in review at this time. A work plan has been drafted to guide the next steps. Feb. 8, 2016: This work has been put on hold due to the impending transition to a new entity.


APPROPRIATELY RESOURCED

8. APPROPRIATELY RESOURCED: Healthy work environment


Injury rates for healthcare workers as low as possible through proper safety training, inspections and organizational commitment to safety.

When workers are off work due to injury, both workload and stress increase for those who cover for injured workers. Workplace Safety and Insurance Board (WSIB) claims increase and premiums may rise. Injuries may result in staff turnover, which disrupts continuity of care and adds to recruitment expenses.

This directly affects all NE CCAC staff. It indirectly impacts all patients of the NE CCAC, due to possible disruption in continuity of care.

Higher job satisfaction for healthcare providers – by reducing stress, keeping workload reasonable and enabling good teamwork and leadership.

Dissatisfied workers may leave their jobs, leading to the problems associated with turnover noted above. Dissatisfied workers may also have more absenteeism and provide lower quality of care or less courteous care if they are feeling stressed or overworked.

Indicators and Trends for Healthy Work Environment Analysis and Ideas for Improvement

The Staff Safety Indicator is calculated as the percentage rate of occupational health and safety incidents reported per full-time equivalent in a given year - annualized and cumulative. Q3 Result: 4.07% 2014-15 Target: ≤ 8.0% 2014-15 Performance Standard: ≤ 10.0% Analysis: The Q3 Staff Safety Indicator result (annualized and cumulative) is below the established target and the Performance Standard. There were 7 employee incidents including the following types:

Slip/Trip (2)

Struck/Caught (1)

Overexertion (1)

Harmful Substance/Environment (1)

Assault (1)

Other (1) Prevention notes:

Three monthly Health and Safety Agenda items dealing with the following topics were published in Q3 for managers to use during their staff meetings: o October: Influenza Flu Clinics, Hand

Hygiene o November: Tire Safety o December: Winter Holiday Travel Safety

A safety reminder regarding walk-ins and working alone was also distributed to teams.

Data Source: Health and Safety Report

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Rat

e o

f O

H&

S In

cid

en

ts (

%)

Quarter, Year

Staff Safety(Frequency of Occupational Health and Safety Incidents)

0

5

10

15

20

25

13-14Q4

14-15Q1

14-15Q2

14-15Q3

14-15Q4

15-16Q1

15-16Q2

15-16Q3

Nu

mb

er

of

Inci

de

nts


Total Number of Employee Incidents by TypeMotor VehicleIncident

Slip/Trip

Other

Assault

HarmfulSubstance/EnvironmentFall

Fire/Explosion

BETTER

BETTER




Q3 Value: 5 Claim submitted to WSIB Analysis: There were 5 claims submitted of which 3 were accepted and 2 were denied by WSIB. The Q3 result is higher than the Q2 result. Ideas for Improvement: Human Resources staff are increasing their knowledge of WSIB claims management practices. Data Source: Health and Safety Report

Q3 Annualized Value: 8.73 days Analysis: The Q3 result is slightly higher than the 2015/16 Q2 result. Ideas for Improvement: Continue guiding managers with attendance program. In Q2 changes are being implemented in the attendance and accommodation program. Note:

Effective Q1 2015-16, this metric is no longer reported on the Balanced Scorecard.

Data Source: HR Indicators

0

5

10

15

20

25

13-14Q4

14-15Q1

14-15Q2

14-15Q3

14-15Q4

15-16Q1

15-16Q2

15-16Q3

Nu

mb

er

of

Inci

de

nts


Total Number WSIB Claims Compared to the Total Number of Incidents

Total # WSIB Claims Total # Incidents

2.00

4.00

6.00

8.00

10.00

12.00

14.00

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Nu

mb

er

of

Day

s


Absenteeism, Number of Days per Eligible Employee (annualized)

BETTER

BETTER




Q3 Annualized Value: 9.96% The Q3 turnover rate is similar to Q2. Notes:

Effective Q1 2015-16, this metric is no longer reported on the Balanced Scorecard.

Employee turnover excludes employees leaving at the end of an assignment period, casual employees and previous retirees.

Data Source: HR Indicators

Analysis: As of December 31, 2015, there were 4 vacant staff positions exceeding 60 days:

1 Physiotherapist – one full-time position in Timmins.

1 Social Worker – one part-time position in Kapuskasing

1 Registered Nurse – one full-time position in Timmins

1 Care Coordinator – one full-time position in Elliot Lake.

Ideas for Improvement: Other staffing models are being considered for difficult to fill therapy positions. Data Source: Staff Vacancy Report

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Q413-14

Q114-15

Q214-15

Q314-15

Q414-15

Q115-16

Q215-16

Q315-16

Turn

ove

r R

ate

(%

)


Turnover Rate (annualized)

0

1

2

3

4

5

6

7

8

Jan'15

Feb'15

Mar'15

Apr'15

May'15

Jun'15

Jul'15

Aug'15

Sep'15

Oct'15

Nov'15

Dec'15

Tota

l Nu

mb

er

of

Vac

ant

Staf

f P

osi

tio

ns

Month, Year

Staff Vacancies Exceeding 60 Days

BETTER

BETTER


PATIENT SAFETY PLAN UPDATE

11. Patient Safety Plan Progress Report

Objective Key Initiatives /

Activities Measure / Indicator

Performance Target

Responsibility

Planned Start /

End Date

Comments and Quarterly Report as of:

October 31, 2015

Goals: To ensure that patient and family-centred care is a guiding principle for the organization.

To ensure that teams are supported in their efforts to partner with patients and families in all aspects of their care.

To ensure that input is sought from patients and families during the organization’s key decision-making processes.

Ensure there is documented and implemented strategy to engage patients and families in not only their care, but also in key decision-making related to patient care.

Define and document the NE CCAC’s Patient and Family Engagement Strategy.

(Leadership 1.3-1.7)

Documented Patient and Family Engagement Strategy

Complete Y/N Senior Director Quality & Information Systems

(A. Matte)

April 2015

March 2016

The Patient and Family Engagement Framework is currently being drafted. Feb. 8, 2016: This work has been put on hold due to the impending transition to a new entity.

Note: also part of the 2015-16 Quality Improvement Plan (QIP).

Establish a strategy for the governing body to regularly hear about quality and safety incidents from patients and families who experience them.

(Governance 10.5)

Established strategy approved by the Board of Directors

Complete Y/N Senior Director Quality & Information Systems

(A. Matte)

April 2015

March 2016

The board receives an update via the Quality, Risk and Patient Safety Report on a quarterly basis. The Patient Services and Quality Committee of the Board as well as the Board are presented with Patient Stories that outline quality and safety incidents. These processes are incorporated into the committee and board work plans annually.

Goal: We will reduce the prevalence of falls for long-stay home care patients.

Reduce falls among long-stay home care patients

Increase completion of the Home Safety Risk Assessment as a teaching tool with patients about safety in the home environment.

(Case Management ROP 14.2)

Process Measure: Percentage of completed Home Safety Risk Assessments for long-stay patients receiving an in-home assessment. (Refer to QIP for data collection method).

80% of patients who receive a RAI-HC have a completed Home Safety Risk Assessment noted in CHRIS.

Falls Prevention Team Lead (C. Croteau)

March 2015

March 2016

Q3 – 83.53%

This is an improvement from the baseline result of 51% in Q4, 2014-15.

A check-box was added to the RAI-HC template to remind Care Coordinators to complete the Home Safety Risk Assessment.

In October, Care Coordination managers

Legend:

Green – Completed

Yellow – Work started, not completed

White – Planned, but not started





Performance Target

Responsibility

Planned Start /

End Date


October 31, 2015

completed further education with staff about completion of the Home Safety Risk Assessment.

Note: also part of the 2015-16 Quality Improvement Plan (QIP).

Goal: To strengthen and reinforce the process of risk event reporting, investigation, and disclosure within the NE CCAC.

To provide learning opportunities for staff and clinicians to learn from risk events.

Ensure that the NE CCAC’s Senior Leaders have an awareness of the patient safety events and the follow-up to address patient safety events.

Monthly Patient Safety Event Report to Senior Leaders.

Monthly report submitted.

Complete Y/N Director, Quality & Risk

(C. Barnhart)

April 2015

March 2016

Monthly reports from April to December have been submitted to Senior Leaders summarizing high and very high patient safety events with preliminary recommendations for corrective actions.

Strengthen and reinforce the process of event reporting, investigation, resolution and disclosure within the NE CCAC to provide safer care to patients.

Develop master report to ensure that Sentinel*Events are tracked for reporting to Accreditation Canada.

(Accreditation Reporting Requirement)

Process implemented to report, track, investigate and resolve sentinel events.


(C. Barnhart)

April 2015

March 2016

Policies and procedures are currently being revised to align with new risk event system. Reporting of Sentinel Events to Accreditation Canada will be incorporated as appropriate.

Documented Patient Safety Event Analysis Guidelines.

(Leadership 15.4)

Approved Patient Safety Event Analysis Guidelines.


(C. Barnhart)

Sept. 2014

Dec. 2015

Disclosure Policy and Procedure is in accordance with Accreditation Standards and best practice.

(Leadership 15.6)

Approved Disclosure Policy & Procedure


(C. Barnhart)

Sept. 2014

Dec. 2015

The Disclosure Policy and Procedure has been revised and is being finalized.

Disclosure and event analysis education for staff.

(Leadership 15.4.3, 15.6.3)

Number of staff who have completed the education.

TBD based on agreed upon processes and staff involved.

Director, Quality & Risk

(C. Barnhart)

TBD





Performance Target

Responsibility

Planned Start /

End Date


October 31, 2015

Goal: The NE CCAC has a Medication Management Framework that includes a strategy

for the management of high-alert medications.

Ensure that medication practices are sustained and improved.

Implement a strategy for the management of high-alert medications for NE CCAC Nurse Practitioners.

(Medication Management 1.7)

Documented process for the management of high-alert medications.

Complete Y/N Director, Clinical Services

(M. Musicco)

April 2015

March 2016

Work in progress.

Goal: The organization’s leaders regularly test the organization’s emergency response plan

with drills and exercises to evaluate the state of emergency preparedness.

Perform regular exercises to evaluate the state of the NE CCAC’s emergency preparedness.

NE CCAC staff will conduct or participate in at least 2 emergency exercises.

(Leadership 14.5)

Number of emergency exercises conducted or participated in by NE CCAC staff.

2 emergency exercises

Director, Quality & Risk

(C. Barnhart)

April 2015

March 2016

One emergency exercise was conducted to test the organization’s business continuity response associated with two different specific scenarios of technology failure’

A plan in place to ensure continuity of services in the event of a labour disruption.

Documented contingency plan in the event of a labour disruption (either ONA or OPSEU).

(Leadership 14.9)

Approved contingency plan

Complete Y/N Director, Human Resources

(C. Cacciotti)

Jan. 2015

March 2016

The labour disruption contingency plan was documented and is complete.


APPENDIX A: QUALITY & RISK STRATEGIES

APPENDIX A: ENTERPRISE-WIDE QUALITY AND RISK MANAGEMENT STRATEGIES

a. Quality Framework and Enterprise Risk Management Framework The Quality Framework outlines the NE CCAC’s commitment to quality improvement in the provision of patient services and a safe, productive workplace. The Framework is aligned with the NE CCAC’s vision, mission, strategic plan and operational plan as well as Accreditation Canada standards. It provides a strategic overview of the key principles and practices necessary for the effective planning, management, delivery and improvement of NE CCAC services.

The NE CCAC Enterprise Risk Management Framework (ERM) supports the identification, assessment, and mitigation of risks through a standardized and documented method.

b. Quality, Risk and Patient Safety Committee (Operational)

The Quality, Risk and Patient Safety Committee provides a mechanism to align enterprise-wide quality improvement, risk management and patient safety efforts occurring at an operational level with the organization’s strategic priorities. The Committee includes representation from a broad range of backgrounds and geographic regions to obtain regional views and perspectives, is chaired by the Director, Quality and Risk, and is accountable to the CEO.

The purpose of the Quality, Risk and Patient Safety Committee (operational) is to:

• Support a culture of quality, risk management, and patient safety at an operational level. • Identify and remove barriers to patient safety and quality of care. • Analyze organizational performance data and translate this data into meaningful opportunities for improvement. • Support quality improvement initiatives. • Identify strategies to mitigate enterprise-wide risks.

c. Patient Services and Quality Committee of the Board of Directors

This Committee provides governance oversight related to risk management in the areas of patient services, patient safety, human resources, ethics and health system partnerships. The Committee provides input into the development of the annual Quality Improvement Plan.

d. Patient Safety Plan

The Patient Safety Plan outlines the North East CCAC’s commitment to Patient Safety and supports the mission and vision through the practice of developing and implementing a culture of safety. The Patient Safety Plan details specific objectives, activities, indicators, responsibilities, and target dates to facilitate meeting the organization’s goals and objectives related to patient safety.

e. Quality Improvement Plan (QIP) The Quality Improvement Plan (QIP) is an annual plan required under the Excellent Care for All Act. This legislation currently applies to hospitals and to the primary health care sector. A Ministry of Health and Long-term Care directive requires that every CCAC shall develop, make publicly available, and submit to Health Quality Ontario their first annual QIP by April 1, 2014 for the fiscal year 2014-2015 using standardized templates and guidance material. As recommended by the CCAC CEOs, the CCAC-specific QIP priority indicators are:

Patient Experience – Percentage of “Good”, “Very Good” and “Excellent” Client Experience Survey responses on a 5 point scale (poor to excellent) to the three patient experience KP 1 survey questions:

Overall rating of CCAC Services;

Overall rating of management /handling of care by Care Coordinator;



Overall rating of service provide by service provider. (Key Performance Indicator 1 – CM Services)

5 Day Wait Times for Nursing Services and PSW Services for Complex Patients

Falls – Percentage of adult long-stay home care patients who record a fall on follow-up RAI-HC assessment.

Hospital Readmissions – Percentage of home care patients who experienced an unplanned readmission to hospital within 30 days of discharge from hospital.

Unplanned Emergency Department (ED) Visits – Percentage of home care patients with an unplanned, less-urgent ED visit within the first 30 days of discharge from hospital.

The NE CCAC QIP is approved by the Board of Directors and submitted to Health Quality Ontario by April 1st of each year.

f. Insurance

The NE CCAC carries insurance protection through the Healthcare Insurance Reciprocal of Canada (HIROC).

g. NE LHIN Risk Registry

This report is no longer required by the NE LHIN. Risks or opportunities that may influence achievement of objectives are

identified during regular joint meetings.

h. Disaster/Emergency Response Planning

The NE CCAC Emergency Management Plan provides a systemic response to any emergency.

i. Pandemic Influenza Planning

The NE CCAC Pandemic Plan provides a systemic response in the case of a pandemic.

j. Document Control (Policies, Procedures and Forms)

The Policy and Procedure Manager software is used to manage policies, procedures and related documents developed to standardize processes within the NE CCAC. Each Senior Director of the Executive Team is accountable for the Table of Contents of their respective portfolio manual and is responsible for delegating, writing and/or editing policies, procedures and related documents to their Managers.

Forms are managed and housed on a SharePoint site. Using SharePoint allows for using electronic forms to their fullest capabilities, including fillable Word forms and InfoPath forms. The Forms Management Committee reviews all forms.

k. Risk Events and Feedback

The Risk Event and Feedback System (REFS) is a database that captures patient risk events and feedback (compliments and complaints), risk events affecting employees, service providers and other third parties, general feedback, health and safety hazards, non-conformances, as well as enterprise-wide risks. A REFS e-learning intranet site ensures that training materials are available to staff throughout the NE CCAC 24/7.

Risk event and complaint reporting is a challenge for many health care organizations with documented reports reflecting only the tip of the iceberg. Maximizing the overall value of the reporting system as a source of actionable data could be a helpful tool to improve patient safety and patient experience.



l. Quality and Risk Newsletter

The Quality and Risk Newsletter is a communication tool to inform all NE CCAC staff about quality and risk issues affecting the organization. The newsletter provides updates on issues related to current systems such as Policy and Procedure Manager, the Risk Event and Feedback System, Patient Safety topics and Accreditation.

m. Accreditation

The NE CCAC participated in the Accreditation Qmentum Survey from May 4-8, 2014 was Accredited with Commendation.

n. Internal Audit/Tracer Strategy

“An audit is a systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which audit criteria are fulfilled.” – ASQ Auditing Handbook

The internal audits were used to evaluate compliance to Accreditation standards and to prepare staff for participation in the Qmentum survey. Internal audits were performed by Quality and Risk Specialists who are American Society for Quality (ASQ) Certified Quality Auditors.

o. Client and Caregiver Experience Evaluation (CCEE)

The provincial Client and Caregiver Experience Evaluation (CCEE) Provincial Committee oversees a coordinated approach of ongoing patient surveys to gather comparable information across and within individual CCACs about the satisfaction and experience of their patients, for the purpose of improving service and reporting to funders and the public. The surveys are currently completed by National Research Corporation Canada (NRCC) using a continuous sampling approach spread over four waves during a one year period. The survey tool has been revised and streamlined to reduce the number of questions and amount of time required for patients or caregivers to respond to the telephone survey.


APPENDIX B: DEFINITIONS

APPENDIX B: DEFINITIONS

Healthcare Quality Improvement: “A broad range of activities of varying degrees of complexity and methodological and statistical rigour through which healthcare providers develop, implement and assess small-scale interventions, identify those that work well and implement them more broadly in order to improve clinical practice.”2 MAPLe Score: The MAPLe score was developed to prioritize patients for access to CCAC services. Patients who have been assessed and have MAPLe scores of high and very high represent the CCAC patients most in need of long term care placement. Performance Indicator: A measurement that is linked to a strategic direction. It demonstrates progress towards a stated goal and identifies areas for improvement. Performance Standard: A corridor or range around a performance target. It is established for variance reporting purposes. It takes into account expected variations such as statistical and seasonal fluctuations in performance. The Performance Standard is indicated by dashed red lines on the graphs. Performance Target: Sets a goal to achieve. It is measurable and used to demonstrate progress towards a stated goal. The Performance Target is indicated by a solid red line on the graphs. Quality in Healthcare: The nine attributes of a high-quality health system, as defined by Health Quality Ontario (HQO), are:

ATTRIBUTES OF QUALITY

OUTCOMES

ACCESSIBLE People should be able to get timely and appropriate healthcare services to achieve the best possible health outcomes.

EFFECTIVE People should receive care that works and is based on the best available scientific information.

SAFE People should not be harmed by an accident or mistake when they receive care.

PATIENT-CENTERED Healthcare providers should offer services in a way that is sensitive to an individual’s needs and preferences.

EQUITABLE People should get the same quality of care regardless of who they are and where they live.

EFFICIENT The health system should continually look for ways to reduce waste, including waste of supplies, equipment, time, ideas and information.


The health system should have enough qualified providers, funding, information, equipment, supplies and facilities to look after people’s health needs.

INTEGRATED All parts of the health system should be organized, connected and work with one another to provide high-quality care.

FOCUSED ON POPULATION HEALTH

The health system should work to prevent sickness and improve the health of the people of Ontario.

Risk: Anything of variable uncertainty and significance that interferes with the achievement of business strategies and objectives. Something goes wrong detracting from the organization’s purpose and the quality of its programs and services. Risk Management: Risk Management is a systematic approach to identify, analyze and respond to risks. Most risks can be managed so that impact to the organization is minimized, mitigated or prevented entirely. Root Cause: The underlying or original cause of an incident or problem.

2 The Ethics of Improving Health Care Quality & Safety: A Hastings Center/AHRQ Project, Mary Ann Baily, PHD, Associate for Ethics & Health Policy, The Hastings Center, Garrison, New York, October 2004.


APPENDIX C: INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT

APPENDIX C: INDICATORS, TRENDS, ANALYSIS AND IDEAS FOR IMPROVEMENT

The nine attributes that reflect a high performing health system are: 1. Accessible 2. Effective 3. Safe 4. Patient-centered 5. Equitable 6. Efficient 7. Appropriately resourced 8. Integrated 9. Focused on population health

To ensure that the NE CCAC is monitoring indicators across the spectrum of the definition of quality, the following section of the report has been organized to link indicators to the applicable attribute of quality For each attribute, from a NE CCAC perspective, there is a definition of “What we want”, “Consequences if we don’t get it” and “To whom does this matter?”. For each indicator there is a mini-graph to indicate progress or lack of improvement over time. The actual indicator, performance corridor (range) and target are displayed on the graphs as shown in the example below:

As applicable, to the right of each graph there is an arrow indicating which direction is “better” for that particular indicator. As well, there is a brief summary of the current status of the indicator along with a brief analysis and ideas for improvement.

0

5

10

15

20

25

08-09Q1

08-09Q2

08-09Q3

08-09Q4

09-10Q1

09-10Q2

09-10Q3

09-10Q4

# o

f D

ays


Wait Time for Patients Referred from Community Settings

Target

Actual

Performance

Standard (range)

BETTER


APPENDIX D: DATE SOURCES

APPENDIX D: DATA SOURCES The following data sources were used to compile the Quality, Risk and Patient Safety Report: NE CCAC Business Intelligence

90th Percentile Wait Time for Patients Referred from Community Settings to Community Home Care

Service Waitlist Analysis Report

5 Day Wait Time

Total Long Stay Wait List, with Transfers (Placement Waitlist)

% of Patients Placed to 1st Choice of LTC Home (LT Placements by Ranking)

Hospital Readmissions or ED Visits

Patients Placed in LTC with MAPLe High or Very High as Portion of Total Patients Placed

Patients with MAPLe Scores High and Very High Living in the Community Supported by CCAC

French-Language Related Complaints

Balanced Scorecard

Home Safety Risk Assessment Report

M-SAA Quarterly Progress Report to the NE LHIN: (2014-2017) OACCAC Members Portal, Reporting Site, MSAA Indicators 2011-2014 Ministry of Health and Long-Term Care,

Wait Time (Days) from Hospital Discharge to Service Initiation (MSAA Indicators, MSAA 1.1.access_wt1)

Risk Event and Feedback System (REFS)

Total Number of Risk events per 1000 Patients (denominator is based on monthly Caseload Snapshot)

Number of Patient Risk Events by Specific Event Type (Top 5)

Number of Patient Risk Events by Risk Level

Total Number of Complaints per 1000 Patients

Complaints by Risk Level

Number of Complaints by Specific Type (Top 5) Complaint Log (Action Line, MPP, NE LHIN and Appeals)

Number of Internal and External Appeals

Number of Internal Appeals by Type

Number of External Appeals by Type (Health Services Appeal and Review Board)

Number of Complaints Referred to the CCAC by the LTC Action Line

Complaints/Inquiries Referred to NE CCAC by MPP Offices and NE LHIN Occupational Health and Safety Incident Reports

Total Number of Employee Incidents by Type

Total Number of WSIB Claims Compared to the Total Number of Incidents Human Resources Quarterly Reports

Absenteeism, Number of Days per Eligible Employee (annualized)

Turnover Rate (annualized)

Staff Vacancies Over 60 Days Evaluations

National Research Corporation (NRC), Client and Caregiver Experience Evaluation (CCEE), Final Aggregate Results, Year 1 (2012-13), Year 2 (2013-14), Year 3 (2014-15).

National Research Corporation (NRC), eReports site, July to September 2015.

quality, risk and patient safety reporthealthcareathome.ca/northeast/en/performance...number of days...

Documents